Chris Urbanski, RPh, MS, FASHP, Director of Medical Affairs
Dennis A. Tribble, PharmD, FASHP, Director of Medical Affairs, Clinical Innovation
David Swenson, RPh, Vice President of Medical Affairs
Crystal Woodward, Manager, Medical Affairs
Francisco Cuesta, RN, MSN(c), Manager, Medical Affairs
Where’s my med?
It’s 9:00 a.m. at Hypothetical Hospital and Nurse Hastings is gathering medications to administer to Mrs. Flannigan in room B222. She has just removed the blood pressure medication from the automated dispensing cabinet (ADC) and is now in search of the patient’s IV antibiotic. She doesn’t see it on the ADC profile and decides to access the refrigerator via override to see if it’s in there. Not finding it, she logs off and calls the pharmacy.
“Did you check the delivery bin on the counter?” the pharmacy technician asks. “I’ll hold while you check.”
“Yes it’s there—I found it,” Nurse Hastings replies. “I thought this required refrigeration?”
“Yes it does, sorry for the confusion. Since it was due at 9:00 a.m. I thought you would be looking for it in the delivery bin,” the technician tells her.
Such is the life of the patient-specific medication: awareness and visibility to delivery and location is generally less than optimal, often resulting in clinician workflow inefficiencies.
The challenges of locating patient-specific medications
A “patient-specific medication” is often described by hospital pharmacists as a medication container or supply that is prepared off the unit, typically in a central pharmacy location, then labeled, dispensed and specifically intended for an individual patient. The medication is prescribed for the individual patient and is not to be shared amongst multiple patients. It typically originates in the central pharmacy and includes compounded sterile products as well as multi-use items such as inhalers, ointments, creams, and eye drops. Patient-specific medications are not routinely stored in Automated Dispensing Cabinets (ADC) in patient care areas, and as a result must be delivered from a central pharmacy location to patients when ordered by a physician. Patient-specific medications can also include individual oral solid or small volume injectable dosage forms—i.e. unit-dose medications—that the pharmacy has chosen not to keep in ADCs.
In our hospital pharmacy experience, patient-specific medications have the potential to create a large amount of medication management issues and frustrations for nurses, physicians, and pharmacists alike. Medication management technologies such as ADCs are designed to store, track, and dispense non patient-specific medications. Medications in ADC’s are readily accessible to nurses on demand. Conversely, our experience suggests that visibility to patient-specific meds is generally poor, adequate control methods for dispensing, delivery and storage in patient care areas are often lacking and management processes are inefficient. This may lead to time spent locating and searching for meds that may have been delivered but are not easily found.
Technology solutions fall short
Though some technology solutions exist that can be used to manage patient-specific meds, they are, in our experience, cumbersome to implement and difficult to maintain, or are adaptions of the technology that lack full visibility and security. Common methods to work around these issues include utilizing storage spaces often shared by multiple patients (for items such as narcotic, pharmacy-prepared sterile products) and multi-patient bulk storage spaces within ADCs that are loaded with medications for individual patients and accessed via override methods. These override methods may not provide enough visibility to allow clinicians to know in advance when the item is actually delivered and stored, nor its specific location—all of which may lead to the frustrations illustrated in the hypothetical scenario above.
Creating simple and intuitive solutions
Now let’s imagine Nurse Hastings’ scene with the same needs for managing patient-specific meds, but different outcomes. Based on our prior experience as hospital pharmacists and nurses, a more ideal scenario would be one in which the solution provides storage for all patient medications in one place, makes their location visible when available, as well as traceable, and provides the level of visibility, safety and security demanded by regulation and standards of care. Similar to non-patient specific medication storage in ADCs, access could be limited to the correct medication for each patient and would track inventory quantities for those authorized users. In this scenario, Nurse Hastings would know exactly where to find the IV antibiotic once it was delivered and available via the ADC profile, including exact storage location and quantities. The solution would also have the potential to ensure that medication supplies follow the patient when they are transferred to another patient care location or are discharged to home.
Exploring new ideas
An internal working group of thought leaders at BD explored this topic with more than 50 clinicians in the field. When asked to consider what a more ideal patient-specific medication management solution might look like, they identified a few areas for consideration, among them: minimal new training, cost effectiveness in that it utilizes existing space allocated for technology, and minimal impact to existing nursing and pharmacy workflows. For these clinicians, an optimized solution would decrease the need to rely on override methods, and clearly show a medication’s description, quantity and location.
Conclusion
Though patient-specific medications do not comprise the majority of medication orders, they have the potential to make up a disproportionate share of troublesome issues including visibility, safety, security, diversion, unnecessary waste and potential increase in inventory cost. Hospital systems have long sought simpler and more intuitive solutions to address these issues.
Learn more
Each month on the BD Institute for Medication Management Excellence blog, thought leaders explore topics of critical importance to medication management, and provide additional ways to learn.
Now that you've read this article, go further by reading the results of a HIMSS Analytics survey on medication management vulnerabilities.